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Prisma Health Opioid Symposium

February 1, 2020

Opioid Crisis OverviewDouglas L Furmanek PharmD BCCCP

Director, Clinical Pharmacy ServicesPrisma Health Upstate

Objectives

• Review the history of opioid use relative to the current epidemic

• Describe the health system impact on the appropriate use of opioids

• Understand opioid pharmacology, morphine milligram equivalents (MMEs), and conversion between agents

• Discuss adjunctive agents used to treat pain

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History of Opioids

• Opium was first reported in 3400 B.C. in Mesopotamia (Southwest Asia)

History of Opioids

• Morphine• Isolated by a German chemist in 1803-1804

• Roughly 10X more potent than processed opium

• “Miracle Drug” used only for severe war injuries and the mentally ill

History of Opioids

• Morphine molecule’s addictive and dependency quickly escalated

• Then family tragedy hit …

• Heroin synthesized from morphine in 1874• Made commercially available by Bayer in 1898

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Opioid Similarities

morphine hydrocodone hydromorphone

codeine oxycodone heroin

Letter to the Editor

Opioid Epidemic !!!

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More than 72,000 Americans died from drug

overdoses in 2017.

2017 Opioid Prescribing Rate per 1000 Persons

11

South

Carolina

Rank: 9th

Opioid RXs (> 90 MME) Dispensed per 100 Persons

12

South Carolina

Rank: 20th

MME = Morphine Milligram Equivalents

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https://www.scdhec.gov/Health/Opioids/

Case for Change: Prisma Health

Hospital Influence on Opioid Dependency

• Studies show:

• 10% risk of chronic opioid usage after “cancer” surgery

• 5-6% risk of persistent usage of opioids post operatively

• 15-25% of post op prescriptions were consumed

• 50% of opioids used for nonmedical purposes are obtained from friends or relatives

J Clin Oncol. 2017 Dec 20;35(36):4042-4049

AMA Surg. 2017 Jun 21;152(6)

Ann Surg. 2017 Apr;265(4):709-714

4 of 5 new heroin users describe

starting with prescription opioids

Analgesics – Quick Overview

Opioid Analgesics Non‐‐‐‐Opioid Analgesic

Act centrally Act peripherally

Addiction, dependence, tolerance Not‐habit forming

Schedule II,III controlled drugs Not controlled drugs

Notable adverse effects:

sedation, respiratory

depression, constipation

Notable adverse effects: gastric

irritation, bleeding, renal toxicity

No anti‐inflammatory effects Anti‐‐‐‐inflammatory effects

No ceiling effects Ceiling effect

Anesthesia and Pain Medicine. 2010 Apr;112(4):810‐33

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Culture Change – Old Practice

Adjuncts (gabapentin / clonidine)

NSAIDs, acetaminophen

Extended Release Opioids

Short-acting or IV Opioids

TR

EA

TM

EN

T

WE

AN

IN

G

Culture Change in Prescribing Practices

Adjuncts (Neurontin / Clonidine)

NSAIDs, Tylenol

Extended Release Opioids

Short-acting or IV Opioids

Non-Pharmacologic Therapies

WE

AN

ING

TR

EA

TM

EN

T

WHO Step Approach

Acetaminophen

• Mild pain

• Ideal for those that should not receive NSAIDs

• Opioid-sparing

• NTE 4 g/day

• (consider all sources)

NSAIDs

• Mild to moderate pain

• Consider ulcerogenicprofile and cardiovascular (CV) risk when selecting agent

• Consider alternative agents in anti-coagulated patients

Opioids

• Severe and breakthrough pain

• Potential for side effects

• Ensure bowel regimen

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CultivateWell-being

Reduce Pain

Improve Quality of Life

Restore Function

SELFCARE

Multi-Dimensional Care

Psycho-Behavioral

Cognitive Behavioral TherapyAddress Mental Health

Meditation

Procedural

Nerve blocksSteroid injectionsLocal injections

Physical

ExerciseMassage

Heat / Cold TherapyAcupuncture

Yoga

*Flor H, Fydrich T, Turk DC. Pain. 1992;49:221-230.

*Gatchel RJ, Okifuji A.J Pain. 2006;7:779-793.

Kamper SJ et al. Cochrane Database Syst Rev.

2014:CD000963.

Medication

AcetaminophenNSAIDS

Adjunctive AgentsKetamine Lidocaine

Treatment of Acute Pain

• Chronic opioid use often starts with treatment of acute pain

• 1 of 8 opioid naïve patients who receive narcotics after a procedure become persistent users

• Patients traditionally use less than 15% of total opioid RX

Shortest therapeutic

duration

Immediate-

release

Lowest effective

dose

N Engl J Med 2016; 374:1501-1504

CDC Guideline for Prescribing Opioids for Chronic Pain; 2016.

http://turnthetiderx.org/treatment/

3 days or less will usually

be sufficient…

>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed

3 days or less will usually

be sufficient…

>7 days rarely needed>7 days rarely needed>7 days rarely needed>7 days rarely needed

Practice Changes:

Re-evaluation of patient

Re-engagement in pain

management plan

Opioids

• “… any drug, natural or synthetic, that has actions similar to those of morphine”

• Considered the most effective analgesics• Mimic the action of endogenous opioid peptides (endorphins) primarily at mu receptors and some at kappa receptors

• Opioid-induced sedation / euphoria can complement pain relief

• Leads to high liability for abuse

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Opioids

Monitor for Opioid-Induced Side Effects

• Key side effects:• Respiratory depression (#1)

• Reduced respiratory effort

• Reduced respiratory rate

• Low blood pressure

• Slow heart rate

• Confusion or dizziness

• Constipation

• Upset stomach

• Dry mouth

Drug Interactions

Interacting Drugs Outcome of Interaction

CNS Depressants

Benzodiazepines

Alcohol

AntihistaminesPhenothiazines

Increased respiratory depression and sedation

Agonist-antagonist opioids Precipitation of withdrawal reaction

Anticholinergic Drugs

Atropine

Antihistamines

PhenothiazinesTricyclic antidepressants

Increased constipation and urinary retention

Hypotensive agents Increased hypotension

Monoamine oxidase inhibitors Hyperpyrexic coma

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2016: The CDC Weighs In

• SPEAK ONE COMMON LANGUAGE for opioids• Morphine Milligram Equivalents (MME)

• Close monitoring

• Reduction or tapering of daily dose

Dowell. MMWR Vol 65;No 1, 3/2016.

JAMA 2016;315(15):1624-45.

90 MME – Risk of overdose

death increases 10X

Calculating MMEs

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

Putting it into Perspective

50 MME / Day

50 mg of hydrocodone 10 tablets of Norco 5/325

30 mg of oxycodone 6 tablets of oxycodone 5 mg

12 mg of hydromorphone 3 tablets of hydromorphone 4 mg

90 MME / Day

90 mg of hydrocodone 9 tablets of Norco 10/325

60 mg of oxycodone 12 tablets of oxycodone 5 mg

24 mg of hydromorphone 6 tablets of hydromorphone 4 mg

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Converting Agents

Empiric 25-50% reduction in calculated equivalent is customary

AVOID

Patch Conversion

Oral morphine (24hr) Transdermal Fentanyl

25mg 12mcg/hr

50mg 25mcg/hr

100mg 50mcg/hr

150mg 75mcg/hr

200mg 100mcg/hr

• NOT indicated for acute pain management

– Delayed onset of action (12 – 24 hours)• T1/2: 18 hours after patch removal

Effects of Opiate Exposure

• Everyone• Short Term

• Pain relief

• Long Term (interpatient variability)

• Tolerance

• ↑ ↑ Amount of drug = Same effect

• Dependence

• Physiologic reliance on drug

• Must experience withdrawal upon discontinuation of drug

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Progression to Addiction

Adjuvant Therapies

• Not typically pain medications

• May relieve discomfort

• Potentiate the effect of pain medications

• Reduce the side effect burden

• Commonly used: • Acetaminophen +/- ibuprofen• Topical agents / creams• Antidepressants • Symptom management meds (mouth coat, antipruritics)

Approach: Neuropathic Pain

Anticonvulsants

Gabapentin/Neurontin®

Pregabalin/Lyrica®

[10% reduction in pain scores]

SNRIs

Duloxetine/Cymbalta®

[25% reduction in pain scores]

TCAs

Amitriptyline/Elavil®

[40% reduction in pain scores]

SNRI = serotonin norepinephrine reuptake inhibitor

TCA = tricyclic antidepressantNeurology 2011;76(20):1758-65.

Am J Med 2009;122:S22-23.

Titrate slowly

2/2 peripheral

edema,

dizziness

Avoid

following MI

or in elderly

patients

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Topical Anti-Pain Agents

• Capsaicin:• “Heat” from red peppers

• Desensitizes and/or depletes substance P

• Moderate to poor efficacy for both nociceptive and neuropathic pain

• Menthol:

• Stimulates the “cold” receptors to cause cool sensation and eleviate pain

• Topical NSAIDs (Aspirin)

• Topical Lidocaine

Safe Disposal of Opioids

FDA Medicines Recommended for

Disposal by Flushing

Buprenorphine Methadone

Fentanyl Methylphenidate

Diazepam Morphine

Hydrocodone Oxycodone

Hydromorphone Oxymorphone

Meperidine Tapentadol

For disposal information, specific to another medication you are taking please visit Drugs@FDA

SC Drop Boxes & Take Back Programs

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Thank You